uu.seUppsala University Publications
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Evaluation of Nutrition Care Process documentation in electronic patient records: Need of improvement
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
Karolinska Institutet, Institutionen för lärande, informatik, management och etik.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Clinical Nutrition and Metabolism.
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Food, Nutrition and Dietetics.
Show others and affiliations
2015 (English)In: Nutrition & Dietetics, ISSN 1446-6368, E-ISSN 1747-0080, Vol. 72, no 1, 74-80 p.Article in journal (Refereed) Published
Abstract [en]

Aim

High-quality documentation in patient records is essential for patient safety and plays a prominent role in the delivery and evaluation of dietetic/nutrition care. We aimed to evaluate dietitians' documentation in patient records according to the four steps in the Nutrition Care Process: assessment, diagnosis, intervention and monitoring/evaluation.

Methods

A retrospective audit of 147 systematically collected outpatient dietetic notes from primary care centres and hospitals in central Sweden was performed using a validated audit instrument. The instrument was used to assess the documentation of 14 items: 10 items focusing on the Nutrition Care Process steps and four items on language clarity and structure, with a maximum total score of 26 for each dietetic note. The notes were divided into three different quality levels, A (high score), B (medium score) or C (low score). Comparisons were made between notes from primary care and hospitals.

Results

The audit showed that the majority of the notes were placed at level B, scoring 13.5–19.5. Only 3% of the notes scored higher than 19.5. The most frequently documented items were intervention (90%), evaluation (70%) and nutrition problem (56%), whereas the least documented items were nutrition prescription (15%), goal of intervention (9%) and connection of problem-etiology-symptom (5%). Flaws in lingual clarity were common (72%). Primary care notes received higher scores than those from hospitals.

Conclusions

The audit shows that Swedish dietetic documentation needs to be improved, for example, by further training and education in the Nutrition Care Process and its standardised terminology.

Place, publisher, year, edition, pages
2015. Vol. 72, no 1, 74-80 p.
National Category
Other Social Sciences Nutrition and Dietetics
Research subject
Food, Nutrition and Dietetics
Identifiers
URN: urn:nbn:se:uu:diva-230205DOI: 10.1111/1747-0080.12128ISI: 000352153400012OAI: oai:DiVA.org:uu-230205DiVA: diva2:739203
Available from: 2014-08-20 Created: 2014-08-20 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Dietetic documentation: Content, language and the meaning of standardization in Swedish dietitians’ patient record notes
Open this publication in new window or tab >>Dietetic documentation: Content, language and the meaning of standardization in Swedish dietitians’ patient record notes
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this thesis was to explore dietetic notes in Swedish patient records regarding content, language and the meaning of standardization.

Firstly, an audit instrument for dietetic notes in patient records, Diet-NCP-Audit, was elaborated and tested. The instrument, a 14-item scoring questionnaire based on the four steps of the Nutrition Care Process (NCP), proved to have high content validity and moderate to high inter- and intra-rater reliability. The instrument was then used in an evaluation of the content, language and structure of 147 Swedish dietetic notes. Although the nutrition intervention and some information about the evaluation were well documented, the overall result showed a need for improvement in several aspects of documentation, such as nutrition prescriptions, goals and the connection between problem-etiology-symptom.

After this, 30 of the audited dietetic notes were also included in a critical linguistic study exploring how the patients and dietitians were referred to in the notes. The dietetic notes contained several linguistic devices that impersonalized and passivized both the patient and the dietitian. Thus, the grammar of the dietetic notes did not enhance or reflect the patient-centered care and the active patient-caregiver relationship that is emphasized in most health care guidelines today.

Finally, a focus group study was performed. Swedish dietitians’ experiences of the standardized Nutrition Care Process (NCP) and its connected terminology (NCPT) were explored and analyzed from the perspective of Habermas’ system and lifeworld concepts. While recognizing many advantages with the NCP and NCPT, dietitians also expressed difficulties in combining the structured and standardized process and terminology with a flexible, patient-centered approach in nutrition care.

In summary, I argue that strategies for the improvement of dietetic documentation are needed. I also suggest that the NCP and NCPT play an essential role in dietetic professionalization. At the same time, however, this standardization may entail the risk of a reductionist view and difficulties regarding how to balance the different ideals of health care. Thus, there is a need for discussions concerning how to use and develop the NCP and dietetic language in a way that ensures the best possible care for the patient.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2015. 88 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Social Sciences, ISSN 1652-9030 ; 118
Keyword
Nutrition informatics, dietitians, Nutrition Care Process, patient records, professionalization
National Category
Other Social Sciences not elsewhere specified
Research subject
Food, Nutrition and Dietetics
Identifiers
urn:nbn:se:uu:diva-263915 (URN)978-91-554-9359-2 (ISBN)
Public defence
2015-11-20, BMC, sal A1: 111, Husargatan 3, Uppsala, 09:15 (English)
Opponent
Supervisors
Available from: 2015-10-30 Created: 2015-10-04 Last updated: 2015-11-10

Open Access in DiVA

No full text

Other links

Publisher's full text

Authority records BETA

Lövestam, ElinKoochek, AfsanehKarlström, BritaAndersson, Agneta

Search in DiVA

By author/editor
Lövestam, ElinKoochek, AfsanehKarlström, BritaAndersson, Agneta
By organisation
Department of Food, Nutrition and DieteticsClinical Nutrition and Metabolism
In the same journal
Nutrition & Dietetics
Other Social SciencesNutrition and Dietetics

Search outside of DiVA

GoogleGoogle Scholar

doi
urn-nbn

Altmetric score

doi
urn-nbn
Total: 982 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association
  • vancouver
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf